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MACC Health Plan (Silver)


Effective January 1, 2015

The following charts summarize benefit information. Please refer to specific benefit sections in the Plan Document and Summary Plan Description for more detailed explanations.

 

NOTE: The Copay will be waived if the person is admitted directly as an Inpatient to the Hospital.

DESCRIPTION OF MEDICAL BENEFITS –

SILVER PLAN

HEALTHLINK OPEN ACCESS III

 

HMO

PROVIDERS

PPO

PROVIDERS

NON-NETWORK

PROVIDERS

LIFETIME MAXIMUM BENEFIT

Unlimited

CALENDAR YEAR MAXIMUM BENEFIT

Unlimited 

Calendar Year Deductible

Single
Family

$250
$500

$500
$1,000

$1,000
$2,000

Calendar Year Out-of-Pocket Maximum (excluding deductibles) 

Single
Family

$2,000
$4,000

$3,000
$6,000

$4,000
$8,000

 MEDICAL BENEFITS

Allergy Services (all) 

80% after Deductible 

70% after Deductible 

50% after Deductible 

Ambulance Services 

80% (Deductible waived) 

80% (Deductible waived) 

(Paid at Participating
Provider level of benefit)

Ambulatory Surgical Center 

80% after Deductible 

70% after Deductible 

50% after Deductible 

Chiropractic Care/Spinal Manipulation 

$30 Copay then 100%
(Deductible waived) 

70% after Deductible 

50% after Deductible 

Diagnostic Testing, X-Ray and Lab Services (Outpatient) 

80% after Deductible 

70% after Deductible 

50% after Deductible 

Durable Medical Equipment (DME) 

80% after Deductible 

80% after Deductible 

50% after Deductible 

Emergency Room Services 

$100 Copay then 80%
(Deductible waived) 

$100 Copay then 70%
(Deductible waived) 

$100 Copay then 50%
(Deductible waived) 

NOTE: The Copay will be waived if the person is admitted directly as an Inpatient to the Hospital. 

Home Health Care

80% after Deductible

80% after Deductible

50% after Deductible

Calendar Year Maximum Benefit

100 visits

Hospice Care

80% after Deductible

80% after Deductible

50% after Deductible

Hospice Bereavement Counseling
(within 6 months of Covered Person's death)

80% after Deductible

70% after Deductible

50% after Deductible

Hospital Expenses or Long-Term
Acute Care Facility/Hospital
(facility charges)

 

Inpatient 

80% after Deductible 

70% after Deductible 

50% after Deductible 

 Room and Board Allowance

Semi-Private Room rate* 

Semi-Private Room rate* 

 Semi-Private Room rate*

Intensive Care

80% after Deductible
ICU/CCU Room rate 

70% after Deductible
ICU/CCU Room rate 

50% after Deductible
ICU/CCU Room rate 

Miscellaneous Services & Supplies

80% after Deductible 

70% after Deductible 

50% after Deductible 

Outpatient 

80% after Deductible 

70% after Deductible 

50% after Deductible 

* A private room will be considered eligible when Medically Necessary. Charges made by a Hospital having only single or private rooms will be considered at 80% of the least expensive rate for a single or private room.

Infertility*

80% after Deductible 

70% after Deductible 

50% after Deductible 

*Benefits are limited to initial exam and diagnostic testing.

Maternity (Prenatal, Delivery and Postnatal)

80% after Deductible 

70% after Deductible 

50% after Deductible 

Mental Disorders and Substance Use Disorders

 

Inpatient

80% after Deductible 

70% after Deductible 

50% after Deductible 

Outpatient

$30 Copay then 100%
(Deductible waived) 

$40 Copay then 100%
(Deductible waived) 

50% after Deductible 

Emergency Care (ambulance and Emergency Room)

$100 Copay, then 100% (Deductible waived) 

$100 Copay, then 100% (Deductible waived) 

$100 Copay, then 100% (Deductible waived) 

Occupational Therapy (OT) (Outpatient) 

80% after Deductible 

80% after Deductible 

50% after Deductible 

Physical Therapy (PT) (Outpatient) 

80% after Deductible 

80% after Deductible 

50% after Deductible 

Physician's Services

 

 Inpatient/Outpatient Services

80% after Deductible 

70% after Deductible 

50% after Deductible 

 Office Visits

$30 Copay then 100%
(Deductible waived) 

 $40 Copay then 100%
(Deductible waived)

50% after Deductible 

 Physician Office Surgery

80% after Deductible 

70% after Deductible 

50% after Deductible 

 Copay applies to the Physician office visit component only. All other services are paid subject to any Deductible and Coinsurance percentages.

Private Duty Nursing 

80% after Deductible 

80% after Deductible 

50% after Deductible 

Prosthetics and Orthotics 

80% after Deductible 

80% after Deductible 

50% after Deductible 

Routine Care
(includes but is not limited to routine physicals, well child care, immunizations, tine test, flu shots, and B-12 injections)

 

Routine Colorectal Cancer Examination (including related laboratory test)

 100% (Deductible waived)

100% (Deductible waived) 

50% after Deductible 

Calendar Year Maximum Benefit

 1 examination

Routine Mammogram

 90% (Deductible waived)

70% (Deductible waived) 

50% after Deductible 

Maximum Benefit Ages 35-39

 1 baseline procedure

Maximum Benefit Ages 40 and over

 1 procedure per Calendar Year

Routine Pap Smear

 100% (Deductible waived)

 100% (Deductible waived)

 50% after Deductible

 Calendar Year Maximum Benefit

 1 pap smear

 Routine Pelvic Examination

 100% (Deductible waived)

 100% (Deductible waived)

 50% after Deductible

 Calendar Year Maximum Benefit

 1 examination

 Routine PSA

 100% (Deductible waived)

 100% (Deductible waived)

 50% after Deductible

 Calendar Year Maximum Benefit

 1 test

 Routine Care – All Other

 100% (Deductible waived)

 100% (Deductible waived)

 Not Covered

 NOTE: Flu shots rendered by Randolph County Health Department will be covered at 100% (Deductible waived).

Routine Eye Examination
(includes refraction)

 100% (Deductible waived)

 100% (Deductible waived)

 Not Covered

 Calendar Year Maximum Benefit

 1 examination

 Skilled Nursing Facility and Rehabilitation Facility

 80% after Deductible

 80% after Deductible

 50% after Deductible

 Combined Calendar Year Maximum Benefit

 100 days

Speech Therapy (ST) (Outpatient)

80% after Deductible

80% after Deductible 

50% after Deductible 

Temporomandibular Joint Dysfunction (TMJ) 

80% after Deductible

70% after Deductible 

50% after Deductible 

Transplants 

100% (Deductible waived)

$1,000 Copay per
transplant then 80%
(Deductible waived)

Not Covered 

Urgent Care Facility 

$35 Copay then 100% 
(Deductible waived)

$50 Copay then 70%
(Deductible waived) 

Not Covered 

Copay applies to the Physician office visit component only. All other services are paid subject to any Deductible and Coinsurance percentages.

Vision Care – Hardware (up to age 19) 

100% 

100% (Deductible waived) 

50% after Deductible 

Maximum Benefit 

1 pair of lenses per Calendar Year and 1 pair of frames every 2 Calendar Years; OR 1 pair of contact lenses per Calendar Year

NOTE: A Covered Person may receive one pair of lenses or one pair of contact lenses per Calendar Year. Disposable contacts will not be subject to the "one pair of lenses" maximum. 

All Other Eligible Medical Expenses 

80% after Deductible 

70% after Deductible 

70% after Deductible 

 

PRESCRIPTION DRUG SCHEDULE OF BENEFITS – GOLD AND SILVER PLANS

 BENEFIT DESCRIPTION

BENEFIT

NOTE: The Covered Person will be reimbursed the amount that would have been paid to a Participating Provider less the applicable Copay if Prescription Drugs are obtained from a Non-Participating Provider.  

Retail Pharmacy: 30-day supply

 

 Generic Drug

 $15 Copay, then 100%

 Formulary Drug

 $25 Copay, then 100%

 Non-Formulary Drug

 $40 Copay, then 100%

Mail Order Pharmacy: 90-day supply

 

 Generic Drug

 $30 Copay, then 100%

 Formulary Drug

 $50 Copay, then 100%

 Non-Formulary Drug

 $80 Copay, then 100%

 

 

PRE-CERTIFICATION ADDENDUM – GOLD AND SILVER PLANS

Note: Pre-Certification Requirements will be revised and updated as necessitated by evolving health care industry standards.

The following list of services will be utilized for Services Requiring Pre-Certification:

 Inpatient Services (Medical, Surgical, Behavioral)

• Bariatric Surgery
• Cervical Spine Surgery (as of 1/1/15)
• Computer Navigation for Orthopedic Surgery
• Elective Admissions
• Emergency Admissions
• Hospice

• LTAC Admissions
• Lumbar Spine Surgery
• Rehabilitation Facility Admissions
• Skilled Nursing Facility Admissions
• Transplants

 Surgical Procedures - Ambulatory

• Bariatric Surgery
• Cartilage Transplant Knee
• Cervical Spine Surgery (as of 1/1/15)
• Cochlear Implant
• Computer Navigation for Orthopedic Surgery

• Lumbar Spine Surgery
• Nasal Septoplasty
• Rhinoplasty
• Sinus Endoscopy
• Sleep Apnea Surgery - LAUP/UPPP, Nasal, and Uvulopalatoplasty

 Ancillary Services

• Home Infusion Services
• Home Health Services
• Home Hospice 

• Occupational Therapy
• Physical Therapy
• Speech Therapy

 Durable Medical Equipment

• Bone Stimulator
• Cardio/External Defibrillator
• Cooling Devices
• CPAP/BIPAP
• Electric Scooters
• Limb Prosthetics 

• Myoelectric prosthetics
• Neuromuscular Stimulators
• TENS Unit
• Wheelchairs (Custom)
• Wheelchairs (Power)
• Wound Vacs

 Diagnostic Imaging - Ambulatory

• Coronary CT Angiography (CCTA)
• Coronary MRA
• Cardiac MRI
• MRA of the Head and/or Neck

• MRI of the Brain
• MRI of the Spine – Cervical, Throacic, Lumbar, Sacral
• PET Scan

 Specialty Infusion Drugs

• Alemtuzumab (Campath)
• Azatidine (Vidaza)
• Bevacizumab (Avastin)
• Bortezomib (Velcade)
• Fulvestrant (Faslodex)
• Immune Globulin (Intravenous)
• Infliximab (Remicade) (as of 1/1/15)
• Mitaxantrone (Novantrone) 

• Oxaliplatin (Eloxatin)
• Paclitaxel (Taxol and Abraxane)
• Panitumubab (Vectibix)
• Pemetrexed (Alimta)
• Rituximab (RituXan)
• Trastuzumab (Herceptin)
• Zoledronic Acid (Zometa) 

 

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